Please Hold for the Doctor

Why you still can’t email your physicians with a simple question. (Hint: It's not their fault.)

Within the next decade, “all individuals, their families, and care providers should be able to send, receive, find, and use health information in a manner that is appropriate, secure, timely, and reliable.” That’s the anemic commitment offered up recently by the Office of the National Coordinator for Health Information Technology in its dazzlingly vague 10-Year Vision. We’ve drifted far off course since 1962, when President John F. Kennedy proclaimed the nation’s intention to “send to the moon … a giant rocket … before this decade is out.” NASA accomplished Kennedy’s heady mission in less than seven years. It will take considerably longer for us to sort out how to exchange electronic health information.

Research and common sense indicate that Americans want to be able to exchange email with their doctors, and it’s easy to see why: There are not enough primary care providers in practice to handle the increasing number of insured patients. New fee-for-value payment models focus on disease prevention or early intervention. Tablets and smartphones are ubiquitous and broadband services widely available. But a 2012 Harris Interactive poll found that only 12 percent of respondents reported having email access to their physicians, although more than half said such communication was important to them. Similarly, a 2012 Consumer Reports survey showed that just 9 percent of participants had contacted their doctors by email within the past year. Inadequate infrastructure, patchy insurance coverage for patients, insufficient reimbursement for providers, and uneasiness on both sides about online privacy have been blamed for the nation’s listless effort to implement electronic health information exchange.

Messages can be categorized as either clinical or administrative. Structured clinical consultations, or e-visits, are carried out by channeling encrypted email through a secure online portal linked to the patient’s electronic health record. The provider responds as he or she would in an office—for instance, by writing a prescription, ordering a lab test or imaging study, referring the patient to a specialist, or recommending a follow-up appointment. Such interaction can replace office visits for nuisance illnesses, saving patients the time, cash, and hassle of missing work and schlepping to the doctor’s office. A large Mayo Clinic study found that patients who opted for e-visits were primarily women taking advantage of the service during working hours. According to Deloitte, about half of Americans’ and Canadians’ 600 million annual primary care visits could be transacted online instead of face to face. Fees for e-visits range from $35 to $75 out of pocket, but can be as little as $15 with an insurance copay.

Advertisement

Secure messaging is also a handy administrative tool. Patients can log in free to an online portal to check lab and test results, pay bills, make appointments, ask questions, and request medication refills or routine dosage adjustments. Messages intended for the doctor are usually triaged by a medical assistant or other staff member. The system is available 24/7, so it’s no longer necessary to confine such business to office hours. The practice benefits, too, by reducing overhead, improving quality, and increasing customer satisfaction.

Doctors clearly have not been trained to do things the Nordstrom way.

Update, June 26, 2014: Medicare’s electronic health records incentive program requires that secure messaging be available, but mandates only one-way communication: In Stage 2, at least 5 percent of an eligible provider’s patients must send him or her a secure message. The doctor, however, is explicitly relieved of any obligation to reply personally. Stage 3 draft recommendations call merely for providers or their staff to send reminders for preventive or follow-up care to at least 20 percent of patients “in the format of the patient’s preference.” The possibility of “electronic episodes of care” may be considered at some future stage.

So why isn’t the medical industry embracing technology as a way to communicate with patients? The twin threats of increased workload and inadequate compensation are primarily responsible for providers’ reluctance to adopt email in their practices. Nearly 1 million U.S. doctors rely on Medicare reimbursement, yet Medicare doesn’t pay them one thin dime for answering email messages or offering e-visits. Two weeks ago tech-friendly physicians gained an important ally when the American Medical Association rescinded its 1994 prohibition on rendering clinical telemedicine services. The group asserted that doctors should be adequately compensated for email consultation and pledged its support for Medicare pilot projects to test innovative payment and incentive systems. The only two under way now, however—the unremarkable Alaska and Hawaii telehealth demonstration projects—are hardly groundbreaking. Privacy and security concerns are another reason providers have snubbed email. And who can blame them? Anxiety over the possibility of a HIPAA breach has escalated to a level of hysteria not seen since the Bay of Pigs crisis.

Despite heading up myriad technology and innovation offices, Medicare clings to an illogical, outmoded definition of telehealth as a way to reach geographically remote populations. Reimbursement is granted for only a narrow spectrum of services, such as depression screening and smoking cessation counseling. Consultation must occur by means of “an interactive audio and video telecommunications system … that permits real-time communication between [the provider] at the distant site and the beneficiary at the originating site.” Asynchronous platforms—email, remote MRI interpretation, and the like—are considered experimental. Inexplicably, the patient must be physically present at the “originating site” (such as a clinic or hospital in a rural, unincorporated, or underserved area) during the encounter, thereby defeating the purpose of telehealth altogether.

Email-averse providers also seem to anticipate receiving more messages than their tech-savvy counterparts actually do. In before-and-after surveys of internal medicine residents and internal/family medicine physicians, 60 percent of the former and 87 percent of the latter found that using email did not increase their workload. A different study revealed that internists in one Philadelphia practice averaged 17 emails a day, only 20 percent of which were replies to patient-initiated messages. Physicians at Kaiser reported receiving just five messages a day on average. “Qualitative evidence indicates that patients are conscious not to be seen to bombard their GP with emails,” comments Helen Atherton, an Oxford, United Kingdom, physician who has written extensively about the role of email in general practice.

Many doctors, however, persist in regarding email as a worthless drain on their time, and incentives to use it are scarce. After all, those in solo and small-group practice who operate within the traditional fee-for-service model can’t bill Medicare for email correspondence. Likewise, salaried doctors aren’t keen on the idea of working harder for the same paycheck. What these practitioners have in common is a desire to improve patient care. A large Kaiser study showed that patient-physician email communication can help stabilize patients’ glycemic or hypertensive status. Other research suggests that email and text messaging can be used, for example, to increase medication compliance, treat eating disorders, lower the rate of emergency department readmissions, and improve quality of life in patients receiving palliative care.

Congress is weighing legislation intended to shore up Medicare’s telehealth payment infrastructure. In addition, Medicaid programs cover electronic messaging in a wider variety of platforms and circumstances than Medicare does, and private payers must match that coverage in 19 states and in the District of Colombia. Several private insurers actually encourage e-visits for nonemergency care and specialist consultations. Humana, for example, urges members to “think of an eVisit like [a] secure Skype™ or Facetime™ session.”

All of these email applications fall under the umbrella of telehealth services, promoted by various factions as telemedicine, mobile health (mHealth), connected health, and e-health. Attempts to standardize the contested terminology in this area have provoked fierce territorial hair splitting. For example, some groups insist that the word telemedicine be reserved for clinical interactions involving physicians. The term mobile health might mean e-visits, remote medical device monitoring, or mammography vans. One new study counted seven discrete definitions of telehealth or telemedicine in use within 26 federal agencies. According to the researchers, this linguistic in-fighting and confusion have stalled the implementation of e-anything.

The industry’s tepid response to the demand for electronic communication sets physicians apart from professionals in other service sectors. Would you patronize an attorney or accountant or real estate agent who could be reached only by phone, and only at her convenience? Or one who had instructed an assistant to read his email and phone you with a reply? Patients have begun to recognize that they are also customers, but doctors clearly have not been trained to do things the Nordstrom way. Letting patients deal with humdrum afflictions and housekeeping details by email could help customer-focused practices attract and retain patients as alternatives to traditional medical care become increasingly appealing. Nearly 40 percent of the nation’s 9,000 urgent care clinics have opened within the past five years, and the number of retail clinics, which now stands at 2,200, is expanding at an annual rate of about 25 percent.

The Office of the National Coordinator for Health Information Technology’s wishy-washy manifesto has somehow failed to persuade grudging physicians to share in its pale vision of unspecified “interoperability across the health IT ecosystem.” For now, then, communication between most patients and their doctors will remain pretty much as it was the day Americans watched the Apollo 11 moon landing on their portable black-and-white TV sets. Will someone please get up and change the channel?